Palliative Care in Oklahoma: Looking Back,

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Palliative Care in Oklahoma: Looking Back,

  1. 1. Palliative Care in Oklahoma: Looking Back, Looking Forward Jeffrey Alderman, M.D.Jeffrey Alderman, M.D. Associate ProfessorAssociate Professor Director, Palliative MedicineDirector, Palliative Medicine OU College of Medicine – TulsaOU College of Medicine – Tulsa
  2. 2. ObjectivesObjectives • Learn about the current state of PalliativeLearn about the current state of Palliative Care in OklahomaCare in Oklahoma • Understand the benefits/pitfalls ofUnderstand the benefits/pitfalls of Inpatient Palliative Care ConsultationInpatient Palliative Care Consultation • Explore reasons why physicians haveExplore reasons why physicians have difficulty with Advance Directivesdifficulty with Advance Directives • Learn what you can do to help patientsLearn what you can do to help patients receive appropriate Palliative Carereceive appropriate Palliative Care
  3. 3. Case Study: Zelda S.Case Study: Zelda S. • Zelda is 73 years old.Zelda is 73 years old. • She has DM-2, Stage III CKD, andShe has DM-2, Stage III CKD, and worsening PVDworsening PVD • She has been admitted to St. John 4She has been admitted to St. John 4 times in the last 6 months withtimes in the last 6 months with symptoms from her ischemic leg.symptoms from her ischemic leg.
  4. 4. Case Study: Zelda S.Case Study: Zelda S. • Zelda is widowed, butZelda is widowed, but has 3 children and 5has 3 children and 5 grandchildren.grandchildren. • Her true love is golf.Her true love is golf. • Her goal of care is toHer goal of care is to continue playing golfcontinue playing golf for as long asfor as long as possible.possible.
  5. 5. Case Study: Zelda S.Case Study: Zelda S. • Zelda’s golf playing is limited by pain.Zelda’s golf playing is limited by pain. • Social Isolation.Social Isolation. • Unclear if Zelda can continue to live alone.Unclear if Zelda can continue to live alone. • Unclear if Zelda ever executed an AdvanceUnclear if Zelda ever executed an Advance DirectiveDirective How can we help Zelda?How can we help Zelda? What if Zelda lives in Oklahoma?What if Zelda lives in Oklahoma?
  6. 6. How Does Your State Rate? Oklahoma F 0% 20% 40% 60% 80% 100% HospitalswithaProgram Oklahoma South Region United States 8/43 401/983 1294/2452 www.capc.org State by State Report Card
  7. 7. TULSA WORLD Saturday October 4, 2008 State gets failing health-care grade BY KIM ARCHER (World Staff) Writer Oklahoma is failing to care adequately for the sickest of its residents and is one of only three states in the country to receive an “F” for access to palliative care, according to a report released Thursday Alabama and Mississippi also received failing grades, according to the study by the Center to Advance Palliative Care and the National Palliative Care Research Center. The study appears in the October issue of the Journal of Palliative Medicine. Palliative care refers to treatment that concentrates on reducing the severity of symptoms rather than striving to halt, delay or cure the disease itself. The goal is to prevent and relieve suffering and improve a patient’s quality of life. Nineteen percent of Oklahoma’s hospitals with 50 beds or more have a palliative care program, the report said. Most are in larger hospitals in Tulsa and Oklahoma counties.
  8. 8. What was measured? • Patient access to palliative care services in hospitals • Patient access to board-certified palliative medicine physicians • Medical student access to clinical training in palliative medicine • Physician access to specialty-level training in palliative medicine Morrison, RS. et al. AMERICA’S CARE OF SERIOUS ILLNESS: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. Center to Advance Palliative Care/National Palliative Care Research Center , 2008, p.14
  9. 9. Why did we fail? • Clearly too few Oklahoma hospitals have Palliative Care Programs • Too few Board-Certified Palliative Care Physicians • Not enough Palliative Care Education for Medical Students • No Fellowship Training Programs
  10. 10. Conclusions • More Oklahoma Hospitals need to develop Palliative Care Programs • More Oklahoma clinicians need training in Palliative Medicine • We must educate the next generation of providers in Palliative Care
  11. 11. University of Oklahoma - St. John Medical Center Palliative Care Service
  12. 12. University of Oklahoma St. John Palliative Care Service • Started in October 2004 - CAPC • Interdisciplinary Team • Inpatient Consults • Close relationship with Hospice
  13. 13. St. John Palliative Care IDTSt. John Palliative Care IDT
  14. 14. University of Oklahoma St. John Palliative Care Service • The Clinical Imperative • The Financial Imperative • Patient/Family Satisfaction • Coordination of Care across Venues of Care • The Educational Imperative • The Quality Imperative • Effective, Patient-centered, Timely, Efficient and Equitable
  15. 15. Education
  16. 16. OU School of Community Medicine in Tulsa • 130 Faculty • 70 – 80 MSIII and MSIV Students • 54 Internal Medicine Residents
  17. 17. Curriculum in Palliative Care • All Senior Internal Medicine Residents spend 60 clinical hours rotating on the Palliative Care Service • All Residents attend 7 didactic lectures • All complete online training in pain and non-pain symptom management
  18. 18. Stanford Curriculum • Introduction to Palliative Medicine • Pain Management • Non-Pain Symptom Management • Communication in Palliative Care • Legal Issues • Terminal Care • Palliative Care Health Care Policy
  19. 19. Clarehouse
  20. 20. Curriculum in Palliative Care • All Medical Students spend ~9 clinical hours rotating on the Palliative Care Service • All Medical Students attend 3 didactic lectures
  21. 21. Future Directions • No formal measurement of Palliative Care Training • Exploring pre/post rotation testing tools • Expand training to the College of Nursing
  22. 22. CONSULT SERVICE Demographic Data
  23. 23. Service Cases 2008 Consults Requested 354 2007 Consults Requested 286 2006 Consults Requested 250 2005 Consults Requested 119 Consult Numbers
  24. 24. 0 5 10 15 20 25 30 35 40 Oct 04 Dec 04 Feb 05 Apr 05 Jun 05 Aug-05 Oct-05 Dec-05 Feb-06 Apr-06 Jun-06 Aug-06 Oct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-08 Apr-08 Jun-08 Aug-08 Consults/Month Patient Volume
  25. 25. 0 5 10 15 20 25 30 35 40 Oct 04 Dec 04 Feb 05 Apr 05 Jun 05 Aug-05 Oct-05 Dec-05 Feb-06 Apr-06 Jun-06 Aug-06 Oct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-08 Apr-08 Jun-08 Aug-08 Consults/Month Patient Volume
  26. 26. Disease Cases Patients Seen 354 Average Age 67.9 Age Range 20 - 98 % Female 53% Referring Physicians 100 Admission DRG’s 118 ICU Referrals 10.2% % Expiring at St. John 31.1% % Entering Hospice After Discharge 33.3% Patient Demographics
  27. 27. Disease Cases % Medicare 72.0% % Medicaid 15.5% % Commercial Insurance 6.0% No Payor Source 6.5% Patient Payor Source
  28. 28. Disease Cases % Cancers 140 39.5 Cardiovascular Diseases 64 18.1 Pulmonary Diseases 37 10.5 Neurodegenerative Diseases 28 7.9 Bone Disease/Fractures 26 7.3 Infectious Diseases 21 5.9 Gastrointestinal Diseases 18 5.1 Renal Diseases 10 2.8 Other Diseases 10 2.8 Background Illness
  29. 29. Number % Pain Management 139 39.3 Direction of Care 109 30.8 Terminal Care 64 18.1 Non-Pain Symptom Management 40 11.3 Other 2 0.6 Reason for Consult
  30. 30. Nephrology 1% OB/GYN <1% Emergency Med 1% Neurosurgery 1% Cardiology 2% Non-OU Internal Med 27% Family Medicine 5% Cardiovasc. Surgery 1% Hospitalists 20% General Surgery 1% Oncology 5% OU Internal Med 35% Referring Physicians
  31. 31. LTAC/SNF – 9.9% Other – 2.7% Expired – 31.1% Clarehouse* – 2.3% Nursing Home – 14.7% Home – 39.3% *’Clarehouse’ is a hospice home in Tulsa, providing care to patients in the last month of life Discharges
  32. 32. Clinical Outcomes
  33. 33. Initial Evaluation Final Evaluation Severe Mod. Mild None Reported Pain Scores 130 Patients seen on the SJMC Palliative Care Consult Service: Oct 2005 – Oct 2006 212 Patients 212 Patients seen on the SJMC Palliative Care Consult Service: Oct 2006 – Oct 2007
  34. 34. Initial Evaluation Final Evaluation Severe Mod. Mild None Initial Evaluation Final Evaluation OU/St. John Mt. Sinai Hospital, NYC* Comparison of Pain Scores 212 Patients 3707 Patients *Data Reported by R. Sean Morrison, MD. Presented at ‘Building Hospital Based Palliative Care Programs.’ sponsored by the Center to Advance Palliative Care (CAPC), San Diego, CA October 2005.
  35. 35. Initial Evaluation Final Evaluation Severe Mod. Mild None Reported Dyspnea Scores 112 Patients 112 Patients seen on the SJMC Palliative Care Consult Service: Oct 2006 – Oct 2007
  36. 36. Initial Evaluation Final Evaluation Severe Mod. Mild None Initial Evaluation Final Evaluation OU/St.John Mt. Sinai Hospital, NYC* 112 Patients 2219 Patients Comparison of Dyspnea Scores *Data Reported by R. Sean Morrison, MD. Presented at ‘Building Hospital Based Palliative Care Programs.’ sponsored by the Center to Advance Palliative Care (CAPC), San Diego, CA October 2005.
  37. 37. Agitation 61.1% Reduction Nausea 82.1% Reduction Constipation 67.3% Reduction Dry Mouth 62.9% Reduction Insomnia 75.9% Reduction Other Clinical Outcomes
  38. 38. Satisfaction Outcomes
  39. 39. Question: Excellent Very Good Good Fair Poor Degree to which pain was controlled 68.4% 15.8% 7.9% 5.3% 2.6% Degree to which symptoms (other than pain) were controlled 77.1% 11.4% 5.7% 2.9% 2.9% Degree to which team addressed Emotional needs 71.4% 14.3% 7.1% 3.6% 3.6% Degree to which team addressed Spiritual needs 76.9% 15.4% 0.0% 3.8% 3.8% Degree to which team included you in decisions about care 71.0% 22.6% 6.5% 0.0% 0.0% Degree to which team treated you with respect and dignity 73.5% 20.6% 5.9% 0.0% 0.0% Degree to which team addressed your overall well-being & comfort 63.9% 19.4% 2.8% 5.6% 8.3% Degree to which discharge process was smooth/hassle free 62.1% 24.1% 0.0% 10.3% 3.4% Overall assessment of Palliative Care team 68.6% 14.3% 14.3% 0.0% 2.9% Telephone Survey of 67 patients/families following discharge date of at least 30 days. Patients were picked at random. Responses from 43 completed surveys are recorded above.
  40. 40. • 83 – 94% responded very favorably, reporting ‘excellent’ or ‘very good.’ satisfaction with Palliative Care at St. John Satisfaction Results
  41. 41. • We received our highest scores in the areas of ‘treatment with dignity,’ ‘inclusion of patients in decisions about care’ and ‘addressing spiritual needs.’ • The highest number of negative comments focused on the discharge process from the hospital. Satisfaction Results
  42. 42. Financial Outcomes
  43. 43. Service Cases LOS Usual Care 1329 11.1 Palliative Care 130 8.5 Savings/Case 2.6 days Length-of Stay-Savings 2008
  44. 44. Year Days Saved 2008 918 2007 1730 2006 931 2005 188 Length-of-Stay Savings
  45. 45. Service Cases Charges/Case Usual Care 1329 $44,602 Palliative Care 130 $30,153 Savings/Case $14,449 Charge Avoidance - 2008
  46. 46. $2,000.00 $2,500.00 $3,000.00 $3,500.00 $4,000.00 $4,500.00 Usual Care Palliative Care Mean Charges Per Day 11 Days Prior to Death 11 10 9 8 7 6 5 4 3 2 1 Days Before Death Charges/Day
  47. 47. Year Charges Saved 2008 $5,114,847 2007 $3,062,573 2006 $3,911,365 2005 $619,750 Charge Avoidance
  48. 48. Putting it Together, LOS and Cost Savings Total Days Saved 2004 - 2008 3,767 Total Charges Saved 2004 - 2008 $12,618,554
  49. 49. Year Days Saved Charges Saved 2009 1343 $5,089,942 2010 1544 $5,852,808 2011 1775 $6,728,228 Looking Ahead into the Future… Assume 15% Annual Growth Rate
  50. 50. Should the Palliative Care Team See Every Patient in the Hospital?
  51. 51. Proactive palliative care in the medical ICU: effects on length of stay for selected high-risk patients Norton SA, Quill TE, et al. Critical Care Medicine 2007; 35:1530-1535
  52. 52. 17-bed medical ICU at a tertiary care hospital in Rochester, New York. Primary Outcome: LOS ICU admission following a current hospital stay 10 days or longer – Age >80 years with 2 or more life-threatening comorbidities – Active metastatic cancer – Status post cardiac arrest; – Intracerebral hemorrhage requiring mechanical ventilation Study Design Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535
  53. 53. Optional PC Consult Required PC Consult Mortality in the ICU 55 59 0 20 40 60 80 100 %Mortality Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535 P > 0.10
  54. 54. 17.7 17.6 9 16.3 0 5 10 15 20 25 30 35 40 HospitalDays Total Days = 26.7 Non ICU Days Total Days = 33.9 ICU Days Required PC Consult Optional PC Consult Length of Stay Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535
  55. 55. Conclusions • Mandatory ICU Palliative Care Consultation reduced ICU stay over 7 days, without substantially changing mortality. • Non-ICU Hospital LOS did not decrease with the intervention Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535
  56. 56. Bottom Line • “Blanket” Palliative Care Consultation can substantially reduce ICU days • Implied in the study is significant cost savings, but not explicitly reported. • More analysis could reveal clinical outcomes, satisfaction level, and referral patterns
  57. 57. The Oklahoma AdvanceThe Oklahoma Advance DirectiveDirective a document only aa document only a lawyer could love…lawyer could love…
  58. 58. Advance DirectivesAdvance Directives •Statement of one’s wishes regarding End-of-Life Care •Only goes into effect when patients permanently lose decision-making capacity •Allows one to opt out of life- sustaining care and/or Artificial Nutrition and Hydration
  59. 59. • Cumbersome document poorly understood by physicians and patients • Only executed by 15 - 20% of eligible patients Gillick, et al., Ann Int Med. 1995;123:621-624 OKLAHOMA ADVANCE DIRECTIVE FOR HEALTH CARE If I am incapable of making an informed decision regarding my health care, I direct my health care providers to follow my instructions below. I. Living Will If my attending physician and another physician determine that I am no longer able to make decisions regarding my medical treatment, I direct my attending physician and other health care providers, pursuant to the Oklahoma Advance Directive Act, to follow my instructions as set forth below: 1. If I have a terminal condition, that is, an incurable and irreversible condition that even with the administration of life-sustaining treatment will, in the opinion of the attending physician and another physician, result in death within six (6) Advance DirectivesAdvance Directives
  60. 60. • Surveys show that patients prefer their physicians to address Advance Directives in a controlled setting (e.g. office) • In reality, most Advance Directives are completed at a point of crisis, such as in a hospital during a critical illness Advance DirectivesAdvance Directives Rodriguez, KL, et al., Soc Sci Med. 2006;62:125-133 Lo B, et al., Am J Geriatr Cardiol. 2004;13:316-320
  61. 61. Behold: The MismatchBehold: The Mismatch •When surveyed, a majority of patients expect their Primary Care Physician to address Advance Care Planning. •Physicians generally do not solicit their patients about completing Advance Directives Tierney, et al. J Gen Intern Med 2001:16;32-40 Lurie, N. et al. J Am Geri Soc 1992:40;1205-8
  62. 62. Office Screening/PreventionOffice Screening/Prevention •Diabetes Screening •Lipid Screening •PAP Smears •Mammography •Colonoscopy •PSA/DRE •Smoking Cessation Counseling •Advance Directive Completion •Alcohol/Drug Abuse Screening
  63. 63. Why is this conversation missingWhy is this conversation missing in Primary Care?in Primary Care? •Thinking about dying is uncomfortable •Patients value invincibility •Physicians value cure •Physicians lack training •Legally complicated process (Missteps = Lawsuit) •Ethical hornet’s nest •Religious Implications •Time Issues •Portability Issues Tulsky J, et al. Ann Intern Med 1998:129;441-449
  64. 64. Can Residents be Trained toCan Residents be Trained to Address Advance Directives?Address Advance Directives?
  65. 65. Study CharacteristicsStudy Characteristics •10 Internal Medicine Residents •100 Clinic Patients •All patients had to have at least one chronic illness to meet entry criteria •Baseline survey of 100 random charts revealed zero AD’s
  66. 66. Study DesignStudy Design •IRB approved, prospective survey trial •Residents were surveyed about their baseline knowledge, skills, attitudes and comfort using Advance Directives with patients. •Residents received 2-hour training period, reviewing all aspects of Advance Directives
  67. 67. Study DesignStudy Design •Once trained, each resident encouraged 10 of their ‘at-risk’ continuity patients to complete an Advance Directive •At the conclusion of the study, residents were re-surveyed about their knowledge, skills, attitudes and comfort using Advance Directives with patients.
  68. 68. 0 1 2 3 4 5 6 7 8 9 10 Knowledge Skill Attitude Comfort Pre-intervention Post-intervention p < 0.001 p < 0.001 p = 0.004 p < 0.001 Results: ResidentsResults: Residents
  69. 69. ConclusionsConclusions •Residents significantly improved their knowledge, skills, attitudes, and comfort with Advance Directives in the Outpatient setting •Patients demonstrated a strong interest in completing Advance Directives
  70. 70. Implications from the StudyImplications from the Study The authors hoped that residents would apply their research experience to engage future patients in completing Advance Directives in the Outpatient setting. Did they?
  71. 71. Epi-PhenomenonEpi-Phenomenon Following the “conclusion” study period, Residents were secretly observed over a period of an additional 6 months Not one advance directive was completed in that period.
  72. 72. Bottom Line:Bottom Line: •Despite intensive training, many barriers are stacked against physicians engaging their patients in meaningful conversations about Advance Directives •The doctor’s office is probably not the right place for patients to complete Advance Directives
  73. 73. Helping Zelda: What can we do?
  74. 74. What Zelda Needs:What Zelda Needs: •Pain Management •Restoration of Function •Assistance with making difficult decisions •Workup and Treatment for Depression •Transition to appropriate venue of care •Advance Directive
  75. 75. What you can do:What you can do: •Be a patient advocate •Recognize and treat patient suffering • Physical Suffering • Emotional Suffering • Social Suffering • Spiritual Suffering
  76. 76. What you can do:What you can do: •Talk to your colleagues – do they recognize suffering? •Learn what resources your community offers in geriatrics and palliative care services
  77. 77. What you can do:What you can do: •If Palliative Care is not in your community, encourage leadership to explore growth opportunities •www.capc.org
  78. 78. What you can do:What you can do: • Complete EPEC/ELNEC training • Become certified in Palliative Medicine • Educate local providers, hospitals, and nursing homes to about Palliative Care
  79. 79. What you can do:What you can do: • Familiarize yourself with the Oklahoma laws regarding Advance Directives • Encourage patients to execute Advance Directives, if they have not already done so.
  80. 80. Thank YouThank You

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